One of the most gruesome and devastating types of traumatic injuries a person can undergo is a degloving injury. Indeed, we had a difficult time finding an image to assign to this article, for fear that an image of a degloving injury would be too gruesome for our readers. In our law practice, we most often see these types of injuries after a high-speed car crash or workplace accident.
What are Degloving Injuries?
The term degloving injury earned its name for the type of injury that results when a hand is “degloved” — meaning the skin is completely pulled off the arm and hand, leaving only the underlying bones, muscles and tissue. This definition, however, does not begin to describe the severity of the injury and the various areas of the body where one can sustain a degloving injury.
Degloving injuries result in serious avulsion of the skin and subcutaneous tissues which may have further complications such as hemodynamic instability, in which your body cannot properly regulate basic functions such as blood pressure. Or, there may be co-occurring fractures from the trauma, injury directly to blood vessels, head trauma and other life-threatening injuries that delay the direct intervention of the degloving injury by the plastic surgeon, until life-saving interventions have been addressed.
A degloving injury involves a detachment of the skin and subcutaneous tissue from the underlying fascia and muscle and has carries a significant mortality and morbidity. This means risk of significant illness and even death.
Four Patterns of Degloving Injuries
The 4 patterns of degloving injuries are:
- Abrasion/Avulsion degloving
- Circumferential, single plane degloving injury
- Circumferential, Multi-plane degloving injury
- Morel-Lavallee Lesions: described below
Main Causes of Degloving Injuries: Car Crashes and Workplace Accidents
These injuries most often occur in motor vehicle accidents in which a pedestrian is struck by a car and dragged by the car along the road, variably losing all of the skin along the affected side. Similarly, this can occur in motorcycle or bicycle accidents. The majority of accidents involve pedestrians and cars. Even pedestrians who were dragged by public buses have been reported in the literature.
Additionally, a closed degloving injury or Morel-Lavallee lesion, caused by pelvic trauma sustained in motor vehicle accidents, can cause massive localized external pelvic bruising, as well as an internal degloving syndrome in which the pelvic soft tissue has torn away from the pelvic fascia and caused liquefied fat and clotted blood.
The other primary cause of degloving injuries are cases of industrial or occupational accidents such as of persons working with large equipment such as in forklifts, tractors, conveyor belts, drill presses and the like, in which a limb gets trapped and pulled into/or crushed by the equipment, pulling the skin off and /or crushing the extremity and causing the “degloving” injury.
These injuries are often caused by the negligence of others — careless drivers, defective machinery, negligent work practices, OSHA violations, etc. Which is why it is important to speak with an experienced, knowledgeable injury attorney as soon as possible to investigate what occurred.
Necessary Treatment for Degloving Injuries
The first order of business when one encounter a degloving injury is an assessment for other co-occurring injuries that may be life-threatening and may be overlooked as a degloving injury is a rather grotesque sight and often commands your attention involuntarily. The on-duty physician must maintain an orderly primary and secondary survey after assessing the ABC’s of trauma care. He or she must maintain focus to access for such common injuries as a punctured lung, head injury, splenic rupture or other injuries that require immediate life-saving care and triage, especially in trauma such as a motor vehicle accident.
Once the patient is declared or made stable from that standpoint, attention is then directed to the limb that has been degloved to determine skin salvage or replantation potential. This would be done by a plastic surgeon, as it will require an extensive array of skin flaps and grafts, and perhaps orthopedic surgeons in cases of concomitant fractures that require surgical intervention. For severe degloving cases, plastic surgeons, orthopedic surgeons, physical therapists and perhaps even infectious disease specialist would all form the team to care for the patient.
The first and best option, as mentioned is replantation or revascularization. When the skin has been physiologically degloved it sometimes can vascularize either by arterial or vein grafts replacing blood flow to the area. Debridement or removal of the dead or damaged blood vessels is imperative prior to implantation of the new blood vessels. In the cases of hand degloving, it is not enough to revascularize the hand and fingers, the nerve supply and sensation must also be restored as well. A technique known as microneural repair of the cut digital nerves is performed.
It is not always possible to salvage the limbs and at times tough decisions must be made, amputation is always a risk. Sometimes fingers, hands, and amputations below the knee must be made. There have been cases of necrotizing fasciitis (flesh-eating bacteria) infection setting in, in which aggressive amputation was necessary to save the life of the patient, as antibiotics are of no use and the disease spreads within minutes, often as quickly as you can amputate one part of the body it has spread like wildfire to the next body part.
These injuries often require multiple surgeries, multiple skin grafts from the patient’s thigh for example, or skin flaps from the patient own abdomen, groin or thigh. Orthopedic procedures to treat fractures sustained in the injury, usually with metal plates and screws, or external fixation devices, and lack of mobility for a period of 6 weeks to 3 months.
Patients suffer from chronic pain due to nerve damage. The inability to do things they once took for granted such as walk, and bathe, or do anything unassisted has caused many to suffer from depression. Depression also is fostered when many cannot resume their typical line of work. Many have to be out of work for a protracted period of time to comply with the physical therapy demands, which are so essential in the prevention of “contractures” which describe a stiff and non- functional limb that occur after skin grafting without proper physical therapy.
Proper therapy includes massage, ultrasound and a variety of exercises. Physical therapy is at a minimum 3-5 days a week for several hours. Wound care also takes a great time commitment, and it involves wound debridement (removal of dead tissue) and is a very painful and slow process. It sometimes needs to be performed in the operating room under anesthesia as it is too painful for the patient.
Cosmetic concerns from scarring of the skin grafts can further contribute to depression or lack of confidence for the patient. The sequential nature of the procedures, especially if your degloving injury included fractures, as so many do, and the time frame of the healing process taking years, may take a toll, with the end product really taking a toll on your quality of life, especially if you are one of the unlucky ones for whom chronic infection results in amputation or for whom significant immobility is a complication. Or for whom contractures have prevented you from basic activities of daily living such as getting dressed, and buttoning your blouse, or performing other household chores such as preparing meals and using a computer due to hand/finger contractures or amputation. The burden is emotional, physical and financial and often permanent.
If you or someone you love has suffered a degloving injury caused by someone else’s careless conduct, such as in a car crash or workplace accident, call the attorneys with expertise in this field of litigation at Passen & Powell at 312-527-4500 for a free consultation.